Insurance Exchanges: New Market Opportunities & Threats to Access. February 2014 avalerehealth.net

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1 Insurance Exchanges: New Market Opportunities & Threats to Access February 2014 avalerehealth.net

2 Despite Slow Initial Enrollment, Exchange Participation Is Accelerating Most Sign-Ups Expected Close to March PROJECTED EXCHANGE ENROLLMENT PATTERN BASED ON PART D VOLUNTARY ENROLLMENT EXPERIENCE (IN MILLIONS) Part D Enrollees Projected Exchange Enrollees Actual Exchange Enrollment One Month Before Deadline for 1/1 Coverage Coverage Begins 1/1 Available March 1, 2014 One Month Before the End of Open Enrollment Available April 1, 2014 End of Open Enrollment *Medicare Part D enrollment numbers based off actual Part D enrollees during the initial open enrollment period in Using the enrollment pattern from Part D and accounting for the differences in length of the open enrollment periods, Avalere projected what a similar enrollment pattern for the exchanges would look like to reach CBOs projected 7M enrollees by the end of the open enrollment period. Source: HHS Health Insurance Marketplace January Enrollment Report. January 13,

3 Plans Strive to Keep Premiums Low, But Have Limited Flexibility on Benefit Design Actuarial Value Essential Health Benefits Out of Pocket Limits With Pressure to Keep Premiums Low, Plans Will Be Focused on Select Levers Network Design: Despite requirements that they must offer adequate networks, plans are designing high-value, narrow networks Formulary Design: Tier placement and utilization management will help plans manage drug use while still meeting EHB drug coverage requirements Guarantee Issue & Rating Rules These parameters constrain plan flexibility Cost-Sharing Requirements: Cost-sharing for specialty products in particular is expected to be high, and plans will structure cost sharing to encourage use of lower-cost products EHB: Essential Health Benefits 3

4 In Spite of Network Adequacy Requirements, Plans are Utilizing Narrow Networks to Design Low Cost Plans CASE STUDY: NUMBER OF PROVIDERS IN LOS ANGELES COUNTY PARTICIPATING IN THE EXCHANGE 2,316 3,009 3,855 4,946 5,705 6,559 8,839 There are 28,181 licensed physicians in Los Angeles County. Number of Providers 0 Health Net Molina Anthem Blue Cross L.A. Care Kaiser Blue Shield PPO Anthem EPO Importantly, services rendered by non-network providers do not count toward the out-of-pocket maximum for exchange plans. *There are 28,181 licensed physicians in Los Angeles County. Source: Avalere PlanScape, Updated November 18, 2013 and Avalere analysis of information available on 4

5 On Average, Silver Plan Deductibles Are More Than $3,000 $6,000 $5,000 AVERAGE MEDICAL DEDUCTIBLES IN FFM STATES, BY METAL LEVEL $4,959 MEDICAL DEDUCTIBLE $4,000 $3,000 $2,000 $1,000 $3,132 $1,713 $1,000 $- Bronze Silver Gold Platinum Source: Avalere PlanScape, Updated January 28, Avalere analysis HHS data file of all exchange plans in FFM states. 5

6 Over 50% of Bronze and Silver Plans, Expected to Have the Highest Enrollment, Use Coinsurance on Their Specialty Tiers FREQUENCY OF COST SHARING TYPE 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% PLAN SPECIALTY TIER COST SHARING IN FFM STATES, BY METAL LEVEL 6% 2% 14% 15% 8% 16% 17% 17% 25% 18% 27% 16% 25% 6% 37% 28% 8% 42% 73% Bronze Silver Gold Platinum Co-Payment No Charge After Deductible Coinsurance: 0%-29% Coinsurance: 30%-49% Coinsurance: 50% and Higher Source: Avalere PlanScape, Updated January 28, Avalere used a deduped version of the official HHS data file of all plans and benefit designs in FFM states to determine cost sharing. 6

7 Plans Disproportionately Use Coinsurance on Specialty Drugs 100% FREQUENCY OF COPAYMENT VS. COINSURANCE BY AMOUNT FOR SINGLE SOURCE BRANDED DRUGS IN SILVER PLANS FREQUENCY OF COST-SHARING TYPE 90% 80% 70% 60% 50% 40% 30% 20% 32% 11% 11% 11% 17% 43% 41% 9% 12% 8% 7% 11% 10% 13% 10% 23% 15% 11% 13% 15% 27% 17% 10% 16% 13% 10% 18% 16% 20% 22% 17% 0% Molecular Target Inhibitors Antiangiogenics Immuno Suppressants Antihepatitis Agents Multiple Sclerosis Agents Copayment Coinsurance: 0-20% Coinsurance: 21-30% Coinsurance: 31-40% Coinsurance: >40% Not Covered Source: Avalere Health PlanScape, a proprietary analysis of exchange plan features. Data as of October 31,

8 Despite the ACA s OOP Limit, Patients May Face High Initial Costs for Their Drugs ESTIMATED SPENDING FOR VERY HIGH-COST DRUGS IN EXCHANGE COVERAGE $7,000 $6,000 $5,000 $4,000 $3,000 $2,000 $1,000 Assumes $15,000 Monthly Drug Cost VT Silver Plan 1 CA Silver Coinsurance Plan MA, NY Silver* OR Standard Silver Plan CT Standard Silver $- First Month's Rx Fill Second Month Source: Avalere Health analysis based on states 2014 standardized benefit designs for silver-level plans in their exchanges. Calculations are based on a prescription drug with a cost of $15,000 per month that is placed on a plan s highest-cost formulary tier. Assumes no other drug or medical spending by the patient during the year. * MA and NY each have a standard silver plan design with the same overall deductible amount, tier 3 cost sharing, and OOP maximum, although the benefit designs differ on cost sharing amounts for other services not included in this analysis. 8

9 An Avalere Case Study on Oncolytics Revealed that Higher Cost Sharing Increased the Risks of Abandonment Avalere Research Found 10% of newly initiated oral agents were abandoned Claims with cost-sharing over $500 were 4 times more likely to be abandoned than claims with cost-sharing of $100 or less Patients with 5 or more prescriptions in the previous month had 50% higher likelihood to abandon than patients with no prescription burden Which Showed Abandonment of newly prescribed oral oncolytic therapy is not uncommon Abandonment increases for patients enrolled in plans with pharmacy benefit designs that require high cost-sharing Higher prescription burden was also associated with a larger abandonment rate Source: L. S. Schwartzberg, S. B. Streeter, N. Husain, M. Johnsrud; The West Clinic, Memphis, TN; Avalere Health, Washington, DC. Abandoning oral oncolytic prescriptions at the pharmacy: Patient and health plan factors influencing adherence. J Clin Oncol 29: 2011 (suppl; abstr 6036) 9

10 Even with Subsidies and Cost Sharing Reductions, Most Chronically Ill Patients Will Be Underinsured in the Exchanges OUT-OF-POCKET CAP AS A PERCENT OF INCOME 1 25% 23% 22% 20% 20% 18% 15% 10% 13% 14% 11% 5% 0% 100% FPL 150% FPL 200% FPL 250% FPL 300% FPL 400% FPL 500% FPL OOP cap as a % of income Underinsured threshold 1. Based on CWF definition: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Available at: rvey_2012_final.pdf 10

11 Complex Balance of Formulary Transparency and Benefits in Exchanges Formulary Transparency In most states, enrollees do not have access to a plan formulary when selecting their plan. Nevada, Colorado, and Vermont are notable exceptions that provide links to plan formularies and, in Nevada s case, a comprehensive formulary look up tool Once enrollees receive their formulary and coinsurance information, lack of information about drug prices limits their ability to understand their true expected OOP expenses As coinsurance grows in prominence, so does price transparency for manufacturers as enrollees learn the true price of their drugs 11

12 Exchange Benefit Design May Accelerate Shift to Narrower Commercial Coverage by Employers EXCHANGE BENEFIT DESIGNS MAY HAVE SPILLOVER EFFECTS BY SETTING A NEW STANDARD FOR COVERAGE GENEROSITY Benefit Design Generosity Less Generous More Generous Commercial Exchange Catastrophic Medicaid Lives Served by Market Today Anticipated Future Market 12

13 Potential Patient Access Issues in Exchanges Formulary Breadth Plans are applying more utilization management controls that limit access to patients medications High Cost-Sharing High deductibles and coinsurance for specialty drugs could increase rates of abandonment Premium Affordability Premiums could increase for plan year 2015, depending on the riskpool in the first year Co-Pay Assistance Manufacturers ability to provide exchange enrollees with co-pay assistance is still an open issue 13